skjelett Nakkeslengskade i sen fase side Krav til drift av privat praksis Tema på kollegabasert veiledningsseminar Se side 11

Transkript

1 muskel skjelett Nummer 1/ årgang Utgiver: Manuellterapeutenes Servicekontor Møter, kurs og seminarer, se side 3 Sa opp direkteoppgjørsavtale med HELFO Side 10 Nakkeslengskade i sen fase side Krav til drift av privat praksis Tema på kollegabasert veiledningsseminar Se side 11 Fastlegene gjør porten vid Side 6 Barn og unge har vi kunnskapen? Tverrfaglig seminar i Oslo mars 2010 Side 30 og 31

2 Redcord Workstation Professional Vår komplette løsning for å jobbe med Neurac metoden Muliggjør en faglig og klinisk spennende hverdag Kan tilpasses alle pasienter Mulighet for Weak Link testing Økonomisk løsning Redcord Stimula Et revolusjonerende verktøy for behandlere Bedre resultater Raskere resultater Hjelp til flere pasienter Last ned produktark på Redcord Stimula muliggjør en ny behandlingstilnærming som er spesielt effektiv i behandling av: Funksjonsforstyrrelser og avvik i muskel-skjelett apparatet Smertetilstander relatert til dysfunksjon i muskel-skjelett apparatet Hva gjør Redcord Stimula? Apparatet tilfører kontrollert vibrasjon via tauene i Redcord Workstation Behandlingen skjer i kroppsvektbærende stillinger Gir i mange tilfeller rask effekt I henhold til ønsket stimuli/behandlingsdosering justeres frekvens, energinivå, vibrasjonsmønster og behandlingstid. Apparatet kan brukes på hele kroppen og har vist seg meget effektivt på blant annet problemer i nakke, rygg og skuldre. En spennende studie gjennomført av Deborah Falla ved Universitetet i Ålborg viser oppsiktsvekkende resultater på behandling av langvarige nakkeproblemer. Studien er ikke publisert, men vil forhåpentligvis foreligge i nær fremtid. Et stort antall terapeuter har allerede tatt i bruk Redcord Stimula. De rapporterer om spennende resultater og erfaringer fra sin kliniske hverdag. For mer informasjon: redcord@redcord.com tlf

3 KURS, MØTER OG KONFERANSER Mars 4. Oslo. Kollegabasert veiledningsgruppe for manuellterapeuter. Tema: Krav til dri av praksis, med og uten dri savtale. Arr.: Manuellterapeutenes Servicekontor. For info og påmelding: Se også side Oslo. Tverrfaglig seminar for manuellterapeuter, leger, kiropraktorer, fysioterapeuter og annet helsepersonell. «Barn og unge har vi kunnskapen?» Arr.: Manuellterapeutenes Servicekontor. For info og påmelding: > Seminar Se program bakerst i bladet Oslo. Kurs i trygdefaglige emner for manuellterapeuter og kiropraktorer. Kurset er obligatorisk for nye manuellterapeuter. Arr.: Universitetet i Oslo. Påmelding: edna.kristensen@medisin.uio.no 19. Oslo. Perinatale risikofaktorer som kan føre til funksjonsforstyrrelser i øvre cervikal columna. Kliniske konsekvenser i spedbarnsperioden. For info, se > Kurs og seminarer April No ingham, England. Neuromatrix conference. Arr.: NOI2010. Les mer: Lørenskog. Kollegabasert veiledningsgruppe for manuellterapeuter. Arr.: NMF. For info, se Mai Køln. European Workgroup for Manual Medicine. Workshops. Manuellmedisin for voksne. For info, kontakt EWMM_2010@manmed.de Juni Bergen. Workshop med Linda-Joy Lee. Tema: System based Classification for Failed Load Transfer. Arr.: Seksjon for fysioterapivitenskap, UiB. For info: September Bergen. Verdenskongress innen laserterapi, WALT Mer info: Oktober Trondheim. Henvisning til spesialist. Videreutdanningskurs for manuellterapeuter, leger og kiropraktorer. Arr.: NTNU i samarbeid med Norsk Manuellterapeutforening. For mer info: Se > kurs November Los Angeles, USA. 7th Interdisciplinary World Congress on Low Back & Pelvic Pain. For info, se Agenda Oversikten over arrangementer er ikke fullstendig. Tips oss om aktuelle kurs, kongresser og seminarer, slik at oversikten blir mest mulig komplett. Kontakt redaksjonen, tidsskrift@manuellterapi.no. Tlf.: muskel&skjelett nr. 1, februar

4 Kun det beste er godt nok! Ta kontakt med oss for tilbud. Benkene kan prøves på vårt kontor i Oslo eller på seminaret i Oslo mars. UNIVERSALBENK Et sikkert valg i sitt segment. Enkel, driftssikker og prisgunstig. er, valg av dropper, farger, versjoner og tilleggsutstyr som faste benker og stoler. OSTEOFLEX Integrert varme i putene er standard (gjelder Luxe). Stilig og stabil benk, med mange variasjonsmuligheter: fasthet, farger og tilbehør. Medinor AS Nils Hansensvei 4 - Postboks 94 Bryn Oslo NB! Nytt tlf. nr

5 muskel skjelett Innhold Rød-grønn privatisering Med mindre regjeringen ombestemmer seg i siste liten vil det skje store endringer i finansieringen av manuellterapi- og fysioterapitjenesten 1. juli. Endringen fører til at behandlere med små kommunale tilskudd som arbeider utover driftsavtalen, vil få betydelige reduksjoner i omsetningen. Vi vet at mange behandlere nå føler seg tvunget til å legge om driften for å kunne imøtekomme økonomiske forpliktelser og unngå oppsigelser. De planlegger å drive utenom den offentlige helsetjenesten og refusjonssystemet for den tiden de ikke har driftsavtale. Pasientene må da betale hele regningen selv. Det er beklagelig dersom regjeringen presser fram en privatisering på denne måten. Det vil være et særdeles dårlig bidrag i sykefraværsarbeidet som regjeringen ellers er svært opptatt av, og ramme de som har dårligst råd. Den 4. mars arrangerer Servicekontoret kollegabasert veiledningsseminar. Hovedtemaet er drift av privat praksis. Her vil deltakerne få råd og tips om hvordan man skal innrette klinikkpraksisen i den nye økonomiske virkeligheten. Det settes også av tid til informasjon og diskusjon om hva som kreves for å være ajour med regnskapslov og skatteregler. Aktuelle temaer for mange i disse tider! Kurs og møter Redaktørens spalte Innholdsoversikt Fastlegene gjør porten vid Sykefraværet vil gå ned Behandling av patellofemorale smerter Et seminar for primærkontakter Psykologiske faktorer ikke relevant Smånytt Manuellterapeut i Drammen sa opp avtale om direkteoppgjør Krav til drift av privat praksis tema på kollegabasert veiledningsseminar Effekt av bekkenbunnstrening Ingeborg H. Brækken disputerte Bertel Rune Kaale: Clinical aspects in the late stage of whiplash injury Ny rapport om muskel- og skjelettlidelser Smånytt Trange sko kan gi feilstilling av stortå Smerter smi er Barn og unge har vi kunnskapen? Seminarprogram og påmelding Tidsskriftet Muskel Skjelett Ansvarlig redaktør Espen Mathisen Nabbetorpveien Gml Fredrikstad tlf.: Utgiver Manuellterapeutenes Servicekontor Boks 797, 8510 Narvik Redaksjonskomite Gro Camilla Riis gro.camilla.riis@manuellterapi.net tlf.: Bjørn Runar Dahl brd@manuellterapi.net tlf.: Harald Markussen harald.markussen@manuellterapi.net tlf.: Annonser Åsmund Andersen, tlf.: asmund.andersen@manuellterapi.net Abonnement Tidsskri et sendes ut fire ganger i året til medlemmer av Manuellterapeutenes Servicekontor. Medlemmer av Unge Fysioterapeuters Fellesskap får bladet gratis tilsendt i Andre kan tegne årsabonnement for 175 kroner. Trykk Møklegaards Trykkeri ISSN Opplag eksemplarer Neste nummer Ca Manusfrist: Interne Les flere saker om muskel og skjele på

6 AKTUELT Elektroniske sykmeldinger bare for leger NAV presiserer at forskriften om elektronisk kommunikasjon ved innsending av erklæringer og uttalelser til Arbeids- og velferdsetaten, bare gjelder leger. 1. januar trådte «Forskrift om elektronisk kommunikasjon ved innsending av erklæringer og uttalelser til Arbeids- og velferdsetaten» (F nr 1285) i kraft. Denne forskriften krever at blankettene «Medisinsk vurdering av arbeidsuførhet ved sykdom» og «Legeerklæring ved arbeidsuførhet» skal sendes elektronisk over linje til Arbeids- og velferdsetaten. NAV presiserer i en epost til foreningene at de andre yrkesgruppene som kan sykmelde manuellterapeuter, kiropraktorer og psykologer i en forsøksordning ikke omfattes av forskriften. Disse kan derfor fortsatt sende inn blankettene på papir. Legeforeningen ønsker normerte sykmeldinger Legeforeningen vil foreslå en beslutningstøtte tilpasset norske forhold, sier legepresident Torunn Janbu. Det er en forutsetning at legen fortsatt skal kunne gjøre en individuell vurdering av hver pasient. Utvikling av beslutningsstøtten må, som i Sverige, forankres i de medisinske fagmiljøene, sier hun. Legepresidenten understreker at beslutningsstøtten må være en veileder for legene som i Sverige, og ikke bindende retningslinjer, slik det ofte har vært fremstilt i norske medier. Fastlegene gjør porten vid Fastleger har en portvaktrolle når det gjelder å sykmelde. Denne samfunnsoppgaven løser de ved å holde porten åpen, sier forsker Benedicte Carlsen. Carlsen fra Rokkansenteret ved Universitetet i Bergen har forsket på hvordan fastlegeordningen påvirker legens skjønnsmessige avgjørelser. På Arbeidsdepartementets fagseminar om sykefraværsutviklingen i januar påpekte hun at fastlegers portvakrolle på sykmeldingsområdet i realiteten er svært svak. Samfunnets portvoktere Fastlegeordningen (FLO) ble innført 1. juni 2001, omfattet alle landets kommuner og allmennleger. Fastlegens portvaktfunksjon ble etablert gjennom henvisnings- og sykmeldingsretten. Ved hjelp av disse ordningene kan fastlegene «åpne opp» adgang til kostbare spesialisthelsetjenester, radiologiundersøkelser, fysioterapibehandlinger og sykepengeutbetalinger. Deres faglige beslutninger skal ligge bak dersom samfunnet skal betale for disse tjenestene og godene. Senere (2006) har manuellterapeuter og kiropraktorer fått lignende rettigheter og rolle på muskel- og skjelettområdet. Pasienten har mer makt Fastlegeordningen har gitt pasientene mer makt. Pasientene kan velge fastlege, og det er dermed blitt viktigere for legen å gjøre pasienten «fornøyd» og imøtekomme pasientenes ønsker, ifølge Carlsen. Maktforskyvningen har ført til at forholdet mellom lege og pasient har endret seg. Mange fastleger opplever at pasientene krever mer og at det er tidkrevende «å forhandle» med pasientene. Usikre Forskningsresultatene viser at de aller, aller fleste pasienter som ber om sykmelding, får det. Fastlegene oppgir tre grunner til at de holder sykmeldingsporten på vidt gap. For det første er de usikker på regelverket. Dernest er fastlegene usikre på de medisinske konsekvensene ved å nekte sykmelding. Til sist er det også mange leger som er uenige i reglene, de mener blant annet at loven er for snever når den ikke tillater at sosiale forhold kan være sykmeldingsgrunn, sa Carlsen. Ifølge Carlsen mener fastlegene at sykmelding er en ubehagelig og vanskelig oppgave, men de vet ikke hvilke andre yrkesgrupper som kan utføre den. Få ønsker beslutningsstøtte Forskerne har også undersøkt hva fastlegene mener skal til for å redusere sykefraværet. 67 prosent av fastlegene støtter innføring av karensdag(er). Mange ønsker også at arbeidsgiver skal pålegges et større økonomisk ansvar og at muligheten for velferdspermisjon med lønn må bedres. Svært få fastleger ønsker beslutningsstøtte, med normerte sykmeldingsperioder, slik som svenskene har innført. 6 muskel&skjelett nr. 1, feb 2010

7 Sykefravær AKTUELT Kommentar Roger Bjørnstad, Statistisk Sentralbyrå. Sykefraværet vil gå ned Sykefraværet vil gå ned med 12 prosent i perioden , ifølge prognoser utarbeidet av Statistisk Sentralbyrå. Regjeringen startet i november en debatt om sykelønnsordningen etter at at sykefraværet steg fra 7,0 til 7,7 prosent i tredje kvartal 2009 sammenlignet med tredje kvartal året før. Statsminister Jens Stoltenberg har luftet flere forslag for å få fraværet ned, bl.a. veiledende retningslinjer for lengde på sykmelding ved ulike lidelser og endret ansvar for arbeidsgiverne. På Arbeidsdepartementets fagseminar om sykefraværsutviklingen nylig presenterte forskningssjef Roger Bjørnstad (bildet) nye prognoser fra Statistisk Sentralbyrå. Ifølge vår sykefraværsmodell blir det en utflating av fraværet i 2010 og en nedgang i 2011 og 2012, omtrent tilsvarende nivået på oppgangen i Det skyldes de dårligere konjunkturutsiktene fremover, sa Bjørnstad. Statistikkpresentasjonene på seminaret viste at antall sykmeldinger på grunn av muskel- og skjelettsykdommer går ned. Muskel- og skjelettsykdommer er imidlertid fortsatt den klart viktigste grunnen til sykefravær. 40 prosent av sykefraværstilfellene skyldes nå muskel- og skjelett. Nest viktigste årsak til sykefravær er lettere psykiske lidelser. Fraværet som skyldes lettere psykiske lidelser er imidlertid en betydelig mindre gruppe enn muskel- og skjelettsykdommer. Manuellterapeuter kan bidra Evalueringen av forsøksordningen som ledet fram til pasientrettighetsreformen viste at når muskel- og skjelettpasienter går direkte til manuellterapeut, reduseres utgiftene til sykepenger. Etter at Stortinget vedtok reformen har det offentlige gjort lite for å markedsføre den. Manglende identifisering av manuellterapeuter gjør det også svært vanskelig å finne fram til manuellterapeuter. Andre deler av helsetjenesten og NAV vet heller ikke sikkert hvem som er manuellterapeut. Dette har i flere tilfeller ført til at henvisninger og sykmeldinger fra manuellterapeuter er blitt avvist. Pasienten har dermed blitt påført unødvendig merarbeid med å skaffe nye henvisninger og sykmeldinger fra lege. Forsinkelsene fører til at sykmeldinger blir unødig forlenget og bidrar til unødvendig oppbygging av sykehuskøene. Manuellterapeutene har spilt inn flere forslag til departementets arbeidsgruppe som skal diskutere sykefraværstiltak. De ønsker seg mer og korrekt offentlig informasjon om pasientrettighetsreformen og en tydelig identifisering av manuellterapeuter. Dette er tiltak som koster lite eller ingenting, men som kaster mye av seg. Om lag 40 prosent av sykefraværet skyldes nemlig muskel- og skjelettsykdommer. Bare en liten prosentvis endring riktig vei vil utgjøre besparelser i flere hundremillioners-klassen. IA-avtalen IA-avtalen forutsetter et effektivt og velfungerende NAV. NAV har imidlertid vært gjennom en stor omstillingsprosess. Det er ennå lenge igjen før etaten kan friskmeldes, og inntil da er det liten grunn å ha store forventninger om at den skal kunne gi øyeblikkelig bidrag til avtalen. Normerte sykmeldinger Legeforeningen går inn for veiledende normer for sykmelding ved ulike diagnoser. Dette er ikke noe godt tiltak. De som har behov for kortere sykmeldinger, vil få for lange sykmeldinger fordi det vil være så alt for lett for sykmelderen å krysse av i henhold til normen. De som har behov for lengre sykmeldinger får problemer med å få en rimelig sykmeldingsperiode, fordi det må begrunnes særskilt og fordi det skal bygges opp et byråkrati som skal godkjenne og kontrollere alle slike saker. Det må for øvrig også være ganske umulig å fastsette en «norm» for hva som er normal sykmeldingslengde for f.eks. et armbrudd. For en snekker kan en slik skade gjøre det umulig å gå på jobb, mens det for en kontoransatt ikke trenger å bety sykefravær av noe betydning. Espen Mathisen muskel&skjelett nr. 1, februar

8 AKTUELT Servicekontorets årlige fagseminar Behandling av patellofemorale smerter Patellofemorale smerter forekommer hyppig hos unge, aktive mennesker. På Servicekontorets tverrfaglige seminar «Barn og unge har vi kunnskapen?» foreleser PhD og manuellterapeut Roar Jensen om diagnostikk og behandling av slike smerter. Av Espen Mathisen Patellofemorale smerter (PFS) er smerter på forsiden av kneet i og ved kneskålen. Andre navn på tilstanden er «fremre knesmerter» og «løperkne». Som regel ser man ikke noe galt med kneet ved røntgen eller andre bildeundersøkelser. PFS er den vanligste skaden blant idrettsaktiv ungdom. Den rammer jenter hyppigere enn gutter. Diagnosen stilles på bakgrunn av sykehistorie og fysisk undersøkelse. En manuellterapiundersøkelse kan i de fleste tilfeller fastslå diagnosen med god sikkerhet. Roar Jensen har i sitt doktorgradsarbeide studert diagnostikk og behandlingsmetoder, og hva som kjennetegner dem som rammes av PFS. Han forsvarte doktorgradsavhandlingen sin i fjor vår. I et av arbeidene indikerer resultatene at PFS-smerter kan være forårsaket av et dysfungerende nervesystem. Akupunktur kan være en behandlingsmetode som hjelper. Jensen har også undersøkt om det er mulig å subgruppere PMF-pasienter. Manuellterapeut Roar Jensen tok doktorgrad på PFS i fjor. I mars foreleser han på årsseminaret. Oslo 5.-7 mars Barn og unge har vi kunnskapen? > Seminar 2010 Har du husket å melde deg på? Det tverrfaglige seminaret «Barn og unge har vi kunnskapen?» går av stabelen mars i Oslo. Dagen før avholdes kollegabasert veiledningsseminar for manuellterapeuter. Info og elektronisk påmelding, se velg «Seminar 2010» i venstremenyen. Et seminar for primærkontakter Seminarets viktigste målgruppe er manuellterapeuter som ønsker å være gode primærkontakter, ikke de som ønsker å bli spesialister i barnemanuellterapi. Agnes C. Mordt i seminarkomiteen sier at som primærkontakter må manuellterapeuter være beredt til å håndtere alle typer pasienter barn, ungdom, voksne og eldre. Årets seminar skal sette oss bedre i stand til å utøve vår primærkontaktfunksjon, sier hun. Undersøkelse og behandling av barn og unge krever i en del tilfeller annen kunnskap og andre teknikker enn når man behandler voksne og eldre. Spørsmålet er når og hvordan dette skal skje. Dessuten må vi kjenne til når det er riktig å henvise og hvor vi eventuelt skal henvise, sier Mordt. 8 muskel&skjelett nr. 1, februar 2010

9 Forskningsnyheter AKTUELT Psykologiske faktorer ikke relevant Psykologiske faktorer er ikke relevant når det gjelder behandling av korsryggsmerter, ifølge dansk-svensk studie. Den danske kiropraktoren Charlotte Leboeuf-Yde (bildet) og medarbeidere har undersøkt hvilke variabler som predikterer (forutsier) utfallet av manipulasjonsbehandling av korsryggsmerter. Informasjon om 731 pasienter behandlet av 55 ulike kiropraktorer i Sverige ble samlet inn. Pasientene svarte blant annet på spørsmål om demografiske forhold, livsstil, kliniske og psykologiske forhold. Spørsmål om bedring ble stilt etter fjerde behandling og etter tre måneder. Resultatene viser at: - Trygdeytelser - Total varighet av smerter siste år - Generell helse var prediktorer ved fjerde behandling. Sensitiviteten var lav, mens spesifiteten var høy. Ved tre måneders-oppfølgingen viste det seg at varighet av smerter siste år og smerter i andre deler av ryggraden hadde sammenheng med behandlingsresultatet. Psykologiske variabler viste seg ikke å ha noen signifikant betydning ved noen av oppfølgingstidspunktene. Forskerne konkluderer med at psykologiske faktorer ikke relevant når det gjelder utfall av manipulasjonsbehandling av korsryggsmerter. Kilde Charlotte Leboeuf-Yde et al.: The Nordic Subpopulation Research Programme: prediction of treatment outcome in patients with low back pain treated by chiropractors - does the psychological profile matter? Chiropractic & Osteopathy 2009, 17:14 Trening mot smerter Kontoransatte kan bruke trening til å forebygge muskel- og skjelettsmerter, viser ny undersøkelse. 549 kontoransatte gjennomførte enten spesifikk trening, generell trening eller referanseintervensjon. Intervensjonene gikk over et år. Resultatene viser at deltakere med ingen eller få smerter ved baseline, også hadde få smerter ved oppfølgningen, uavhengig av hvilken gruppe de tilhørte. Personer som hadde muskel- og skjelettsmerter ved studiestart, hadde signifikant mindre smerter i nakke, korsrygg, armer og hender ved oppfølgningen. Det danske arbeidsmiljøsenteret, Københavns universitet og Syddanske Universitet og Norges Idrettshøyskole står bak studien som er publisert i Manual Therapy. Kilde Andersen LL, Christensen KB, Holterman A, et al. Effect of physical exercise interventions on musculoskeletal pain in all body regions among office workers: A one-year randomized controlled trial [Epub ahead of print]. Manual Therapy 2009; Forandringer i lårmuskulaturen ved PFSS Taiwansk studie viser sammenheng mellom patellofemoralt smertesyndrom (PFSS) og dysfunksjon i vastusmuskulaturen. 54 pasienter med PFSS og 54 friske kontrollpersoner ble undersøkt med ultralyd. Det viste seg at festet til vastus medialis obliquus satt nærmere midtlinjen på patella hos PFSS-pasientene enn hos kontrollpersonene og fibervinklingen mellom vastus medialis obliquus og rectus femoris var mindre. Muskelvolumet var også mindre enn hos kontrollpersonene. Forfatterne av studien mener at disse anatomiske forskjellene påvirker dragkraften og effekten av vastus medialis obliquus slik at den ikke klarer å stabilisere kneskålen skikkelig. Men det er usikkert om det er de anatomiske forskjellene som forårsaker symptomene ved PFSS eller om det er motsatt at PFSS skaper endringer i vastus medialis obliquus. Mei-Hwa J et al.: Differences in Sonographic Characteristics of the Vastus Medialis Obliquus Between Patients With Patellofemoral Pain Syndrome and Healthy Adults, Am J Sports Med September 2009 vol. 37 no muskel&skjelett nr. 1, februar

10 AKTUELT Drift av privat praksis Sa opp avtale om direkteoppgjør Etter en regnskapskontroll fra Skatt sør bestemte Åsmund Andersen seg for å si opp direkteoppgjøravtalen med HELFO. Ingen pasienter reagerer på at de må betale for hele behandlingen til meg. De er bare overrasket over at de kan få noe igjen fra HELFO, sier manuellterapeuten fra Drammen. Av Espen Mathisen Da Andersen i fjor fikk besøk av skattekontrollørene (se Muskel&Skjelett 3/2009) påpekte de mangler ved økonomirutinene hans. Når pasientene ikke betaler egenandel etter hver behandling skal dette ifølge Skatt Sør registreres som utestående fordring eller kredittsalg. Det ble ikke gjort i journalsystemet. Jeg var derfor nødt til å legge om rutinene, sier han. Trener mer selv Skatt sørs undersøkelser viste også at HELFO hadde innrapportert et annet beløp til skatteetaten enn det Andersen selv hadde Nye pasienter reagerer ikke i det hele tatt. De er faktisk mer overrasket når de får beskjed at de får igjen penger! mottatt i refusjoner. Selv fikk han ingen årsrapport fra HELFO som kunne forklare forskjellene. I tillegg innebar direkteoppgjørsordningen at manuellterapeuten hadde penger utestående fra HELFO 365 dager i året. Alt dette til sammen gjorde at jeg bestemte meg for å si opp avtalen om direkte oppgjør med HEL- FO 1. september i fjor. Jeg varslet samtidig om at jeg fortsatt ville ta imot pasienter på trygdens regning. Mer primærkontakt Andersen sier at direkte pasientbetaling har ført til en sterkere dreining mot primærkontaktrollen. Mange pasienter trenger plutselig ikke manuellterapi når de må legge ut penger og ordne med refusjoner selv. De trener mer selv, og tar bare kontakt dersom det skulle være noe spesielt. Behandlinger med minimal effekt, som tidligere ble gjennomført fordi de ble dekket av trygden, gjennomføres ikke lengre. Innkjøringsproblemer De første 14 dagene hadde Andersen en del innkjøringsproblemer. HELFO og NAV ga motstridende beskjeder når det gjaldt hva pasientene trengte av papirer for å få utleggene sine refundert. Manuellterapeut Åsmund Andersen sa opp direkteoppgjøravtalen med HELFO i september i fjor. Han måtte også ta kontakt med journalleverandøren ProMed for å få til sikker og rask fakturautkjøring til pasienten. Det ble utviklet en ny ProMed-versjon for min situasjon. Nå taster jeg inn koder alt etter tidsbruk og arbeid, klikker «ferdigbehandlet» og printeren spytter ut en stykk regning fysioterapeut. Deretter klikker jeg «lag faktura» som gir oversikt hvilke utlegg pasienten skal få refundert. Pasienten betaler med kort eller kontant i resepsjonen og får fakturaen stemplet betalt. Hver dag kan jeg gå hjem med 100 prosent av arbeidet inne på kontoen min. I pakt med regnskapsloven Gjennom den nye faktureringsrutinen får Andersen et sporbart system som imøtekommer skattemyndighetenes krav når det gjelder kredittsalg. 10 muskel&skjelett nr. 1, februar 2010

11 Drift av privat praksis AKTUELT Obs! Nå går denne arbeidsprosessen helt knirkefritt for min del, jeg angrer bare på at jeg ikke har gjort dette før. Hvordan reagerer pasientene på at de må betale alt til deg og hente refusjonen sin selv hos HELFO? Noen av de gamle traverne synes det er tungvint. Men nye pasienter reagerer ikke i det hele tatt. De er faktisk mer overrasket når de får beskjed at de får igjen penger! Pasienter som betaler bare egenandel, sier noen ganger at de ikke gidder å heve refusjonen sin på HELFO fordi det dreier seg om småbeløp. Om dette er noe de bare sier vet jeg ikke, men det viser jo at pasientene er villige til å betale mye mer enn dagens egenandel. Andersen forteller at pasientene er misfornøyd med at HELFO noen ganger har ventet opptil to-tre måneder før de har fått behandlet sitt refusjonskrav. Ifølge pasientene er det også umulig å få direkte kontakt med HELFO i Tønsberg, hvor saksbehandlingen foregår, for eventuelt å purre. Jeg skjønner jo at HELFO sliter fra tidligere 12 regninger elektronisk per år til nå regninger hver dag i papirform. Men det er jo bare å tilby en avtale som er bedre, så skal jeg se på muligheten å levere elektronisk igjen. Mer kontroll Andersen har ikke lenger noe utestående økonomisk hos HELFO, det er pasientenes sak. Likevel sier han at HELFO prøver å gjøre det så tungvint som mulig for han, uten at han tror de lykkes særlig. Jeg har fått mistenkelig mange anmodninger fra HELFO om å utdype pasientopplysninger, hvorfor slik og slik, tidspunkt for oppstart i forhold til skade og så videre. Jeg har aldri i tiden med oppgjørsavtale fått noen anmodninger om å utdype noe som helst ovenfor HELFO med hensyn til diagnoser og lignende. Men det er vel kanskje fordi HELFO vil slite mer med eventuelle krav ovenfor pasienter i ettertid, hva vet jeg. Hvordan slår direkte fakturering av pasienter ut når det gjelder dine utgifter? Det går med mye papir og printertoner? Jeg kjører svart-hvitt laserprinter, men tenker ikke på utgiftene. Tidligere tapte jeg renteinntekter på å ha penger utestående fra HELFO. Sparer også porto og CD-rom til HELFO. Andersen sier seg alt i alt er meget fornøyd slik han har det nå. I fremtiden kan det være at jeg står bedre rustet dersom pasientene pålegges å betale mer eller alt selv. Drift av privat praksis tema på kollegabasert veiledningsseminar Rammebetingelsene for drift av privat praksis har endret seg kraftig på kort tid. Kommunene skal overta en større del av det økonomiske ansvaret og at staten via refusjonene skal redusere sitt. Myndighetene og NFF ble i fjor enige om at en del omleggingen skulle gjennomføres i Hovedomleggingen skjer imidlertid fra 1. juli Drift med og uten driftstilskudd Spesielt manuellterapeuter med små tilskudd men som arbeider ut over driftsavtaletiden, vil merke endringene i form av nedgang i omsetningen. Faren for at ventelistene vil vokse, er overhengende. Hvilke muligheter er til stede for at både pasient og behandler vil komme ut av dette på en tilfredsstillende måte? Advokat Jan Birger Løken vil presentere den nye finansieringsordningen og diskutere temaet praksis med og uten driftstilskudd og forholdet til refusjoner. Regnskap Mange manuellterapeuter har fått pålegg fra Skatt sør etter en gjennomgang av regnskapene blant privatpraktiserende i Buskerud. De har måttet bringe i orden bokføringssystemene. Servicekontoret har invitert Skatt sør til seminaret for å fortelle om resultatene fra undersøkelsen i Buskerud. Manuellterapeutenes Servicekontor har bedt et revisjonsfirma om å foreta en grundig gjennomgang av bemerkningene til Skatt sør. Dette for å kunne gi medlemmene konkrete råd. Resultatet av denne gjennomgangen vil bli presentert på seminaret. Kjennskap til, og gode råd om bokføring, gir muligheter til å være godt forberedt når skatteinspektørene banker på døren. Ansvarforsikring og NPE I 2009 ble det påbudt for privatpraktiserende helsepersonell å ha ansvarsforsikring i Norsk Pasientskadeerstatning (NPE). NPE er invitert til å informere om ansvarsforsikringen og hvordan manuellterapeuten bør forholde seg i aktuelle situasjoner. Les mer om og meld deg på Kollegabasert veiledningsseminar: > Seminar muskel&skjelett nr. 1, februar

12 FORSKNING Bekkenbunnstrening Effekt av bekkenbunnstrening Manuellterapeut Ingeborg Hoff Brækken har i sitt doktorgradsprosjekt vist at veiledet bekkenbunnstrening hos kvinner kan redusere grad av underlivsprolaps, redusere symptomer og skape endringer i bekkenbunnen. Ingeborg Hoff Brækken forsvarte sin avhandling om effekten av bekkenbunnstrening ved underlivsprolaps, 21. januar 2010 ved Norges idrettshøyskole. Bakgrunn og formål med prosjektet Grunnet en høy forekomt av underlivsprolaps (prolaps/nedfall/fremfall av blære, livmor og/eller tarm) blant kvinner og tilhørende problemer er det et stort behov for å identifisere risikofaktorer, forebygging og behandling av lidelsen. I dag mangler dokumentasjon på effekt av bekkenbunnstrening for å redusere og forebygge prolaps. Kun sparsom dokumentasjon finnes om mulige endringer i bekkenbunnens morfologi (form og fasong) og funksjon etter bekkenbunnstrening. For å evaluere slike effekter er det nødvendig med gyldige målemetoder. Målet med avhandlingen var å evaluere ultralydmålingenes repeterbarhet, identifisere risikofaktorer for prolaps, evaluere effekt av bekkenbunnstrening i forebygging og behandling av prolaps og å dokumentere morfologiske endringer i bekkenbunnene etter slik trening. Prosjektet er støttet med EXTRAmidler fra Helse og rehabilitering og Norske Kvinners Sanitetsforening (NKS). Ultralyd For å evaluere test-retest intratester reliabilitet av to-, tre- og firedimensjonal ultralydmålinger ble 17 deltagere undersøkt to ganger. Resultatene viste at de fleste målingene var reliable og kunne bli benyttet i forskning for å evaluer endringer i bekkenbunnen etter bekkenbunnstrening. Risikofaktorer for underlivsprolaps 49 kvinner med prolaps og 49 kontrollkvinner deltok i studien. Univariate analyser viste ingen assosiasjon mellom gruppene i postmenopausal status, røyking, fysisk aktivitet med lav intensitet, fødelsforløsning (keisersnitt, tang, vakuum), fødselsvekt, strekkmerker, rectusdiastase og generell hypermobilitet i ledd. Ingeborg Hoff Brækken Kvinner med prolaps hadde lavere styrke og utholdenhet i bekkenbunnsmuskulaturen og lavere hviletrykk enn kvinner uten prolaps. Body mass index (BMI), sosioøkonomisk status, tungt fysisk arbeid, anal sphingter rupturer under fødsel og funksjon i bekkenbunnsmusklene var uavhengig assosiert med prolaps. BMI og funksjon i bekkenbunnsmusklene synes å være viktige faktorer da disse selv kan endres av kvinner. Bekkenbunnstrening i forebygging og behandling av underlivsprolaps 109 kvinner ble tilfeldig trukket til trening (n=59) og kontrollgruppe (n=50). Begge gruppene fikk informasjon om lidelsen og ble rådet til å trekke sammen bekkenbunnsmusklene før hosting, nysing og tunge løft og å unngå å trykke nedover (f.eks. ved avføring). Kvinnene i treningsgruppen skulle trene 3 sett med 8-12 sammentrekninger av bekkenbunnsmusklene i seks måneder. I tilegg fikkk de individuell oppfølging hos fysioterapeut. Resultat: 19% av kvinnene i treningsgruppen versus 8% av kontrollene bedret grad av prolaps. Kvinnene i treningsgruppen reduserte frekvens og plager av prolapsrelaterte, blære og tarmsymptomer, bedret styrke og utholdenhet i bekkenbunnsmuskulaturen, økte muskeltykkelse, eleverte posisjon på blære og tarm, reduserte arealet på levator hiatus og forkortet lengden på bekkenbunnsmusklene sammenlignet med kvinnene i kontrollgruppen. Konklusjon Studien viser at veiledet bekkenbunnstrening kan redusere grad av prolaps, redusere symptomer og skape morfologiske og funksjonelle endringer i bekkenbunnen. 12 muskel&skjelett nr. 1, februar 2010

13 Whiplash FORSKNING Clinical aspects in the late stage of whiplash injury Dette er et sammendrag av Bertel Rune Kaales doktorgradsavhandling, lagt fram høsten 2009 ved Universitetet i Bergen. Avhandlingen bygger på de fire artiklene: 1) Whiplash-associated disorders impairment rating: neck disability index score according to severity of MRI-findings of ligaments and membranes in the upper cervical spine (2005), 2) Head position and impact direction in whiplash injuries: association with MRI-verified lesions of ligaments and membranes in the upper cervical spine. (2006) 3) Active range of motion as an indicator for ligament and membrane lesions in the upper cervical sine after a whiplash trauma (2007), og 4) Clinical assessment techniques for detecting ligament and membrane injuries in the upper cervical spine region a comparision with MRI results (2008). I sammendraget refereres disse til som artikkel 1-4. Bertel Rune Kaale, kaale@c2i.net 1. Introduction 1.1 The whiplash syndrome (WAD) Harold Crowe was the first to use the term whiplash in 1928 to describe the manner in which the head is moving to produce a neck sprain (Crowe 1928). The term whiplash injury appeared for the first time in a medical journal in 1953 (Gay et al. 1953). Since 1951 and until today there are registered approximately 6200 scientific articles on the term whiplash. The interest in the whiplash syndrome has exploded over the last years, as judged by the number of publications revealed by a literature search (PubMed, February 2009: Whiplash ). More than 4500 are published after 1996, above all after Earlier studies, from the nineteen-seventies until the -nineties, focused mainly on in vitro studies, biomechanical laboratory testing and histological studies (Fielding et al. 1974, Dvorak et al a, b and c, Dvorak et al. 1998, Saldinger at al. 1990, Panjabi et al a, b), whereas an increasing number of studies focusing on psychosocial stress and cognitive and psychosocial aspects related to the late whiplash syndrome appeared from the nineteen-nineties (Van der Donk et al. 1991, Schrader et al. 1996, Karlsborg et al. 1997, Richter et al. 2004, Kivioja et al. 2004). Radanov described in 1992 two different groups of syndromes after whiplash injuries. One syndrome was called the cervicocephalic syndrome, characterized by headache, balance problems, disturbed accommodation, poor concentration, increased sensitivity to light, and pronounced fatigue. The other syndrome was called the lower cervical syndrome and was characterized by cervical and cervico-brachial pain. Radanov argued that whiplash associated disorders had not been recognized in clinical practice, as the clinicians often did not enquire about changes of the cranio-cervical complex when they referred a patient for further radiological or neurological examinations (Radanov et al. 1992). The Québec Task Force presented their widely accepted definition of whiplash in They found from reviews of the literature a great heterogeneity of definitions and classifications of all aspects related to WAD. They concluded that this syndrome was an celerationdeceleration mechanism of energy transfer to the neck. This mechanism could result in bony or soft tissue injuries, which in turn may lead to a wide variety of clinical manifestations. The Quebec Task Force Classification divided whiplash-associated disorders (WAD) into 5 groups (Table 1) (Spitzer et al. 1995): Table 1. Clinical Classification of Whiplash-Associated Disorders. Grade Clinical presentation 0 No complaint about the neck. No physical sign(s) 1 Neck complaint of pain, stiffness or tenderness only. No physical sign(s) 2 Neck complaint and musculoskeletal sign(s)a 3 Neck complaint and neurological sign(s)b 4 Neck complaint and fracture or dislocation a. Musculoskeletal signs include decreased range of motion and point tenderness b. Neurological signs include decreased or absent deep tendon reflexes, weakness and sensory deficits. (Spitzer et al. 1995). 1.2 Existing models for the understanding of the chronic whiplash syndrome The underlying causes of symptoms and complains among WAD patients are not well known or understood. Both psychosocial and organic models have been proposed and most previous studies have focused on either of these two main models. Probably, both organic and psychosocial mechanisms may be Sammendraget er fra Clinical aspects in the late stage of whiplash injury. Dissertation for the degree of philosophiae doctor (PhD), University of Bergen, Norway, muskel&skjelett nr. 1, februar

14 FORSKNING Whiplash at work, as it is in most patients with chronic pain (Hulsebosch et al. 2008, Jenewein et al. 2009). It is beyond the scope of this thesis to give a full account of all launched theories and models. However, a few aspects and models will be dealt with briefly below Organic models biomechanical mechanisms Clinical studies, in vitro studies, biomechanical laboratory testing, radiological studies and histological studies have over time focused on soft tissue injuries in the cranio-cervical junction as a possible consequence after a whiplash trauma (Fielding et al. 1974, Dvorak et al a, b and c, Dvorak et al. 1998, Saldinger at al. 1990, Panjabi et al a and b, Bogduk et al. 2001, Krakenes et al. 2001, 2002, 2003 a, b, Myran et al. 2008). Adams has in fatal cases demonstrated that serious neck injury with atlanto-occipital and atlanto-axial dislocations occur in traffic accidents (Adams 1992 a and b). These authors focused on specific soft tissue lesions as a possible explanation for the long lasting consequences in chronic whiplash syndromes. The work by the Québec Task Force group emphasized this possibility of an organic origin to the chronic whiplash syndrome (Spitzer et al. 1995). The biomechanical limit of harmlessness in two-car rear-end collisions is assumed to be a velocity change due to the collision of between km/h. Morphological and anatomical signs of injury to the cervical spine have not been demonstrated below this change of speed range (Castro et al. 1997). Studies have demonstrated that nerve root compressions after whiplash injuries can produce pain. Such nerve root compression can mediate nociceptive cellular changes, and thresholds for pain and nociceptive pathophysiology may be lower after neck injuries (Rothman et al. 2005, Hubbard et al. 2008). Injuries to the brainstem and the circulatory system after whiplash injuries have also been demonstrated by Endo et al. Vertebrobasilar artery insufficiency may lead to cervical vertigo and dizziness after whiplash injuries (Endo et al. 2006) Psychosocial models Several researchers have focused on psychosocial aspects as a possible explanation of the chronic whiplash syndrome. Psychosocial factors may influence the posttraumatic course after a whiplash injury in at least two different ways, either by a premorbid personality that makes the patient more susceptible to develop chronic pain, or a change of the personality in a negative direction caused by the chronic pain. It appears difficult to distinguish with any certainty between these two possibilities (Van der Donk et al. 1991). The work done by the Québec Task Force in 1995 focused on a possible psychosocial model together with an organic model for the understanding of the whiplash syndrome (Spitzer et al. 1995). Results from other studies have given some support to the psychosocial explanation model for WAD2. Schrader and co-workers studied the natural course of head and neck symptoms after rearend car collision in Lithuania. They concluded that the chronic symptoms were usually not caused by the car accident. On the contrary, they argued that expectation of disability, a family history, and symptoms existing prior to the trauma may be more important determinants for the evolution of the late whiplash syndrome than organic changes caused by the accident (Schrader et al. 1996). Karlsborg et al. was of the opinion that the acute symptoms after whiplash traumas can be explained by the neck sprain, but that the pathogenesis of the late whiplash syndrome and the reasons why only some people have persistent symptoms after more than 6 months remain unknown. They concluded that long-lasting distress and poor outcome after a whiplash trauma were more related to the occurrence of stressful life events than to clinical findings after neck trauma (Karlsborg et al. 1997). Richter et al. later supported this understanding. They focused on prognostic factors for the duration and severity of acute symptoms in subjects with grade 1 or 2 whiplash injuries. They found no correlation between severity and duration of symptoms and collision parameters, and concluded that psychological factors were found to be more relevant than collision parameters in predicting the duration and severity of symptoms (Richter et al. 2004). Kivioja et al. have compared psychiatric morbidity between two groups: patients having chronic symptoms after a whiplash injury and patients who recovered completely. Their results showed that a history of psychiatric disease or stress was more common in patients with chronic neck and head symptoms after a whiplash trauma; therefore they concluded that psychiatric morbidity might be a patient-related risk factor for the development of chronic symptoms after a whiplash injury (Kivioja et al. 2004). 2.0 Aims of study The aim of the present study was to explore the possibility that symptoms and signs, and also abnormal neck movements in WAD patients, could be related to organic changes in the cranio-cervical region, as judged by MRI. We also explored whether the MRI-verified changes could be related to accident-related factors among WAD patients (Krakenes et al. 2002, 2003a,b). A total of five different neck structures assumed to be particularly vulnerable to forces acting during a whiplash episode were evaluated. A brief description of the anatomical function of these structures may be helpful and is therefore given below. 14 muskel&skjelett nr. 1, februar 2010

15 Whiplash FORSKNING 2.1 The biomechanics of the cranio-cervical junction The following is an attempt to explain some of the basic principles underlying the biomechanics of the cranio-cervical junction, with special emphasis on the 5 structures studied in the present thesis: the left and right alar ligaments, the transverse ligament, the tectorial membrane and the posterior atlanto-occipital membrane. Ligaments are in general less elastic than membranes, as the content of collagen fibres is higher in ligaments. This applies also to the structures studied here. The tectorial membrane is a broad, strong band. Also the atlanto-occipital membrane is broad, but much thinner compared with the tectorial membrane (Williams et al. 1980). The ligaments and membranes may affect the function in the cranio-vertebral junction in two possible ways. They may limit the excursions in the joints simply by acting as passive restraints, or they may affect the function through their proprioceptive innervation, and thus indirectly modify the active movements in the region. Lesions to ligaments elsewhere in the body may contribute to local pain and disturbance of coordination and proprioception. Human ligaments may vary, also between individuals, with variations in density and pattern of distribution of nociceptors and mechanoreceptors (Cavalcante et al. 2004, Hagert et al. 2005, Tamai et al. 1999, Petrie et al. 1998, Schutte et al. 1987). This may give individual differences in pain and biomechanical dysfunction after a soft tissue lesion. (Cavalacante et al. 2004, Hagert et al. 2005, Morisawa 1998, Schutte et al.1987, Tamai et al. 2000, Petrie et al. 1998, Mashoof et al. 2001). Stability of the spine and specifically the cranio-cervical junction is one of the major objectives during a neck trauma (Dvorak et al. 1988). In the cranio-cervical junction, the alar and transverse ligaments provide much of this stability. The alar ligament restrains rotation, flexion and side bending, whereas the transverse ligament restricts flexion as well as anterior displacement of the atlas (Dvorak et al. 1987, 1988) The ligaments The alar ligaments and the transverse ligaments are very strong, with an approximate in vitro strength of 200 N and 350 N respectively (Dvorak et al. 1987, 1988). The alar ligament is stretched, and thus possibly more vulnerable to overstretching, when the head/neck is rotated and in addition flexed. A neck trauma could lead to irreversible overstretching or rupture of the ligaments since they consist mainly of collagen fibres (Dvorak et al. 1987, 1988). An invitro study from Tominago et al. investigated the strength of neck ligaments following a whiplash trauma, with the aim to determine the dynamic mechanical properties of whiplash-exposed human cervical spine ligaments. Bone-ligament-bone specimens were tested. They investigated the anterior and posterior longitudinal ligaments, capsular ligaments, interspinosus and supraspinous ligaments and the flavum ligament. The results showed that neck ligament strength was decreased following a whiplash trauma. They concluded that this decrease in ligament strength provides support for the ligament-injury hypothesis of the whiplash syndrome (Tominago et al. 2006). Panjabi et al. came to the same conclusions. They tried to quantify the strains in the cervical spine ligaments during simulated frontal impact and investigated the injury mechanisms. They focused on the supraspinosus and interspinosus ligaments and the flavum ligament. Their results indicated that excessive strain during frontal impacts puts strain on ligaments, and that the investigated ligaments therefore may be at risk for injury (Panjabi et al. 2004) The membranes The passive stability in the cranio-cervical junction provided by the cranio-cervical membranes is not well defined. Farley supports the idea that the tectorial membrane is a primary stabilizer of the occiput- C2 region (Farley et al. 2005), implying that injury to this specific membrane will induce instability in this region. There is also some evidence that damage to the posterior atlanto-occipital membrane may influence the posterior aspect of the cranio-cervical stability (Zumpano et al. 2006, Nash et al. 2005). 3.0 Material and methods These aspects are described under the same heading in the 4 separate publications of this thesis. More details on the process behind the inclusion of patients and controls persons, and other aspect in the Material and Methods chapters are given below. 3.1 Study population This study comprises information about 92 persons with a diagnosis of whiplashassociated disorder, grade 2 (Quebec Classification of Whiplash-Associated Disorders - Spitzer et al., 1995) and 30 control persons. The study has been approved by The Regional Committees for Medical Research Ethics and The National Data Inspectorate Board Random selection of WAD patients The WAD-2 patients included in this study was a randomly drawn sample of persons diagnosed with WAD-2 after being involved in a car accident in 7 communities in the county of Sogn and Fjordane, Norway during the period 1992 to The diagnosis was set by local physicians. A total of 342 persons had been diagnosed during this period. These 342 persons were referred to Firda medical centre shortly after the medical assessment for treatment by a physiotherapist. muskel&skjelett nr. 1, februar

16 FORSKNING Whiplash The WAD-2 inclusion criteria were neck complaint and musculoskeletal signs after the consensus findings in Quebec in The diagnosis was based on symptoms and signs after a car accident. A final establishment of the diagnosis was made after weeks, ensuring that only patients with chronic symptoms were recorded. Plain X-rays of the neck were normal and no patient had neurological deficits. During the period from 1992 to 1995, and thus before publication of the Quebec consensus (Spitzer et al 1995), the medical doctors followed the criteria from Hirsh et al. and Norris et al. (Norris et al. 1983, Hirsch et al. 1988). The grading system of Norris et al. is very similar to the QTF classification system. The classification according to Norris et al. has only 3 groups, with neurological signs only in group 3, while the QTF grading have four groups, with neurological deficits in groups 3 and 4. At time of diagnosis, and thus shortly after the accident, all the WAD patients completed a questionnaire on accident-related factors. The patients were asked to give information on whether they had been sitting with the head/neck turned to one side at the time of impact or not, and also on the direction of impact, that is whether the car was hit in front or from behind. Only patients who were able to give information on these aspects of the accident were included in the study. Moreover they were instructed to report date of the accident, and report on any occurrence of prior car accidents. The questionnaire was completed at the medical office or at the first visit at Firda physiotherapy centre. In 1999, the final recruitment of study participants took place. Of the initial 342 eligible patients, a total of 45 were excluded because information on accident-related factors was missing or incomplete, they had sustained a previous neck injury, or they had been sitting in the back seat. Of the remaining 297 eligible WAD-2 patients, a total of 100 individuals, 50 randomly drawn from each of the two groups defined by neck position, were invited to participate in the study. Information about the research project was attached. Of the 100 invited persons, a total of 93 gave their informed consent to participate, whereas 7 rejected or did not answer Random selection of control persons A total of 300 persons that fulfilled pre-defined inclusion criteria for serving as control, were identified. Inclusion criteria were that the persons had been treated by a manual therapist at Firda Medical Center (FMC) for conditions unrelated to neck problems during the same period as the recording and inclusion of the WAD patients ( ). Exclusion criteria for the control group were any known previous neck injury or neck complaints. On an initial annual list we ranked all patients in the order they had arrived at the medical center. To secure a chronologically even distribution, we tried to include approximately eligible persons every year. The number of selected controls each year was not completely equal, since the diagnostic system in our software before 1995 had more diagnoses that were less specific, such as myalgia and muscleskeleton dysfunction. We excluded persons with such non-specific diagnoses, since they could imply that the person also had neck problems. We also category matched on gender, that is we selected the same proportion of males and female patients as in the total population of 297 eligible WAD patients. No specific routines were followed to get a similar age distribution. FMC had the only manual therapist in the county of Sogn and Fjordane at that time, and the control persons were thus recruited from the same geographic area as the WAD patients. A total of 100 individuals, randomly drawn from the list comprising 300 names, received a preliminary request about participation in the study, together with information about the research project, and a question on whether they had experienced a neck trauma since the previous treatment sessions. Of 75 control persons that were willing to participate, 5 had been exposed for a WAD trauma. A final control group comprising 50 individuals was then randomly drawn from the 70 eligible control persons without neck trauma, and a final invitation for participation was sent out. Of these 50 persons, a total of 38 agreed to participate, whereas 12 gave a negative or no answer. In our original study protocol, we planned to draw control persons from the general population in the county of Sogn and Fjordane. For practical reasons, however, partly related to a time delay caused by reduced capacity within Statistics Norway for selecting control persons, we were advised to select control persons from a specific patient population instead. Unfortunately, the description of the control material was not updated when the first paper (Kaale et al. 2005a) was published. However, an erratum has been published, together with a conflict of interest statement (Kaale et al. 2006; enclosed as attachment to Article no. 1) The questionnaires and the clinical tests It was the intention of the study to approach the WAD complex from different points of view, with the hope of exposing important clinical aspects of the condition. Some aspects of these methods will be presented below. The 93 WAD patients and the 38 control person who had agreed to participate in the study were assigned a date for clinical examination as well as MRI. The clinical testing of passive mobility of neck, as well as the tests for active range of motion in different directions (AROM), was performed on the same day, and 4-6 days before the MRI assessment. All these test procedures and collection of data on clinical symptoms were performed during the period September 1999 to March Eight of the control persons (7 men and 1 woman) did not 16 muskel&skjelett nr. 1, februar 2010

17 Whiplash FORSKNING show up on the MRI examination day. Moreover, due to a claustrophobic condition that made it impossible to perform an MRI examination, one of the WAD patients was later excluded. The final study population thus comprised 92 WAD-2 patients and 30 control persons. The mean time from the collision to the MRI examination was 6 years (range years) The NDI questionnaire The participants completed and returned the neck disability index (NDI) questionnaire at the time of the clinical examination (Attachment 3). This questionnaire was a modification of the Oswestry Low Back Pain Index translated into Norwegian, comprising 10 single items related to activity of daily living. The scores reflected self experienced and self reported degree of neck pain and/or difficulties with performing certain activities due to neck pain. The participants completed and returned the neck disability questionnaire at the time of the clinical examination, i. e. 1 9 years after the accident The AROM test and the clinical test of passive mobility These clinical tests were performed on the same day, a few days before the MR examination. For three persons, who became worse after testing, we had to postpone the MRI examination, which however took place within 2 weeks. The goal with the clinical tests was to find out if they could be used as indicators for soft tissue lesions in WAD patients. The clinical test attempted to assess the passive mobility in the upper cervical spine, by testing specific ligaments and membranes. The test of active range of motion (AROM) focused on active movements, to see if they were restricted or if the WAD patients had larger movement ranges than normal controls. The test of active range of motion (AROM) focused on the ROM as a possible indicator for increased of reduced total cervical ROM as a consequence after a neck trauma. Five WAD patients and 1 control person got more severe symptoms in the head and neck after a manual pre-testing, and did therefore not undergo the subsequent AROM testing. The number of study participants in the paper presenting results from AROM (Kaale et al. 2007) thus differs slightly from the other papers. The two tests were performed a few days before the MR examination. For three persons, who became worse after the AROM test and the clinical test for passive mobility, we had to postpone the MRI examination, which however took place within 2 weeks. Another five persons belonging to the WAD2 group and one person in the control group got more severe symptoms in the head and neck after a manual pre-testing, and did therefore not undergo the subsequent AROM testing. 3.3 The MRI examinations The MRI examinations were performed during the period September 1999 to Mars All participants underwent MRI with a 1.5 T system (Magnetom Vision; Siemens Medical System, Erlangen, Germany). A standard head coil was used, and all images were obtained with the head and neck in a neutral position. More details about the MRI protocol and reliability of the MRI assessments are given elsewhere (Krakenes et al. 2001, 2002, 2003a, b) and will not be repeated here. The mean time and time range from the collision to the MRI examination varied between 6 years (range years) and 5.7 years (range ). The reason for this difference was that fewer patients were included in Article 3, see above. The MRI examinations were in general performed within 1 week after the clinical tests. However, three persons felt bad after AROM test and clinical testing, and we had to postpone the MRI assessment, which took place within 2 weeks Blinded MRI evaluations All MRI evaluations were performed blinded for study groups as well as for results for the clinical tests. The manual therapist (BRK) that performed the clinical testing was not blinded for study group, but was blinded for the MRI results. Thus, the comparisons of NDI-score between WAD patients and control persons were blinded for study group, as were the analyses of possible associations between NDI-score and the severity of MRI findings among WAD patients (Kaale et al. 2005a). Moreover, the comparisons of MRI results between WAD patients and control persons, and according to accident-related factors (Kaale et al. 2005b), were also performed blinded for study group. The comparison of AROM between WAD patients and control persons (Kaale et al. 2007) however, was not blinded for study groups since the clinical testers had been the patients therapists. When relating AROM to severity of MRI findings among WAD patients, however, the analyses were blinded for study group. When evaluation reliability of the clinical test, using MRI as gold standard (Kaale et al. 2008), in joint analyses of results for WAD patients and controls, classifications made by the two raters were mutually blinded. 4.0 Results Detailed accounts of the results are given in the included 4 articles. Here only brief summaries will be given. 4.1 Article 1 In the first study we examined if WAD patients differed from control persons regarding symptoms and level of daily living as represented by a Neck Disability Index (NDI) score. We also examined muskel&skjelett nr. 1, februar

18 FORSKNING Whiplash if there were associations between self-reported symptoms, and the extent of changes in the MRI signals of the included structures, and whether WAD patients differed from control persons in these respects. Our results showed that WAD patients scored significantly higher on the 10 single items in the neck disability index (NDI) score than the control persons did. The difference was particularly pronounced for problems with neck pain, reading, headache, concentration, car driving, and overall activity level. Among the WAD patients, the NDI score increased significantly with increasing severity of MRI abnormalities of the alar ligaments. For the other included structures: the transverse ligament, the posterior atlanto-occipital membrane, or the tectorial membrane, we did not find any significant association between the NDI scores and the observed MRI changes. However, the disability score increased with increasing number of abnormal (grade 2-3) structures among the WAD patients. 4.2 Article 2 In the second study we examined whether the MRI findings were associated with accident-related factors hypothesised to be of importance for severity of the injury. Our results showed for all neck structures considered, that the chronic whiplash patients had significantly more MRI high-grade changes than the controls. Changes in the alar ligaments were most common; as 66% of the patients had pronounced MRI changes (grades 2 or 3) in this structure. The lowest prevalence of high-grade MRI changes was seen for the tectorial membrane. None of the control persons had the most pronounced MRI change (grade 3) in any of the 5 investigated structures, but grade 2 change was observed for the alar ligaments and the posterior occipital-membrane in three persons. WAD patients who reported that they had the head rotated at the instant of collision had more often high-grade MRI changes of the alar ligaments than those with the head in a neutral position. Nearly two thirds (61.7%) of the patients with rotated neck position had alar ligament grade 3 changes, as opposed to only 4.4 % in the patient group that had reported a neutral neck position. The association between assumed head position and high-grade changes (grade 2-3) of the alar ligaments was more pronounced in rear-end than in front collision. High-grade changes in the transverse ligament were also more common among patients with the head turned at the instant of collision. Pronounced MRI changes in the transverse ligament and the posterior atlanto-occipital membrane were considerably more common in front-end than in rear-end collisions. Almost one third (31.5%) of the patients with a front-end collision had grade 3 changes of the transverse ligament, compared with 2.6 % for patients with a rear-end collision. The corresponding figures for the posterior atlanto-occipital membrane were 20.4 % and 0.0 %, respectively. 4.3 Article 3 In this study we examined whether the range of active neck motion (AROM) differed between patients and controls, and whether the range of motion in any way was associated with the MRI findings. If ligaments and membranes are overstretched during an accident, one might expect that this would lead to a hyper-mobility at the cranio-cervical junction. Such a neck hyper-mobility could not be demonstrated in the patients. On the contrary, the WAD patients had on average a shorter range of active neck motion for all movements compared with the control group. Gender- and age-specific analyses revealed a significant difference between the patients and the controls in flexion and extension among men only, whereas the difference in rotation and side bending was most evident for women, in particular in women below 45 years. For both the right and left alar ligaments, the maximal range of active flexion decreased significantly with increasing severity of the MRI changes among the WAD patients. No significant association was found between changes in the alar ligaments and maximal extension. The range of active rotation, however, decreased with increasing severity of MRI changes in the alar ligaments. Maximal range of active rotation also decreased with increasing severity of changes in the posterior atlanto-occipital membrane. No significant association was found between AROM and MRI changes in the transverse ligament or the tectorial membrane. The associations between flexion and rotation on one side and MRI changes in the alar ligaments on the other remained statistically significant in gender and age adjusted analyses. 4.4 Article 4 In our fourth work we examined if there was any association between the range of passive mobility, as estimated by manual techniques, and the MRI findings. Considering all four-response categories/grades, the kappa coefficient showed moderate agreement (range ) between the clinical evaluations, as revealed by clinical tests and the MRI classifications. Most disagreements were close, however, and when adding weight also to cases without complete agreement in the calculations, the weighted kappa coefficient indicated good agreement (range ). When dichotomising the classification results by combining the two best (0-1) and two worst (2-3) categories, agreement was good for the ligaments (values close to 0.70), and very good for the two membranes (values above 0.90). The very high degree of agreement for the membranes is probably 18 muskel&skjelett nr. 1, februar 2010

19 Whiplash FORSKNING partly related to the low prevalence of abnormal findings for these structures. In the case of disagreement, the structures were rated significantly lower by the clinical test than by the MRI classification. However, in most cases the clinical and MRI classifications differed by only one grade. The sensitivity, specificity and positive and negative predictive values of the clinical test vs. MRI for the different ligaments and membranes were in general rather good. For the two ligaments, however, about 30-35% of the abnormal MRI results did not have a clinically detectable correlate (sensitivity of 0.69, 0.72 and 0.65 for the right and left alar ligaments, and the transverse ligament, respectively). 5.0 Discussion The overall aim of the present study was to examine whether clinical symptoms and signs in WAD patients could be related to physical injuries to specific soft tissue structures in the neck region, as judged by MRI. In the present series of studies, we found that WAD patients reported significantly more pain and functional disability than control persons; the prevalence of abnormal MRI findings was also significantly higher in WAD patients. Among WAD patients, the MRI verified changes were related to severity of symptoms, range of passive and active neck mobility, as well as accident-related factor. So far, these results have not been reproduced by other investigators. In a sensitive and much disputed area of medicine as this, it is of the utmost importance that the association between radiological and clinical findings is reproduced. Until so happens, our results must be interpreted with caution, as always should be the case when new evidence is presented. Larger sample size is also needed to achieve more precise results. The costs associated with the use of the hospital s MRI equipment and personal resources, precluded a larger number of participants in the present study. Our results are discussed in details in the included articles. Those discussions will not be duplicated here. Instead, certain aspects of the methodology, particular those related to validity and reliability, but also some other aspects, will be discussed. Some of these methodological aspects were too detailed to fit into the frame of the individual articles, whereas others simply did not cross my mind until I had started the process of writing this thesis together. 5.1 Additional information on study participants To which extent one can generalize the results from this work depends very much on how representative the samples of WAD2 patients and control persons are. The use of inclusion and exclusion criteria, together with the sample sizes may directly influence the results. The inclusion and selection of patients was based on information given by the patients themselves in addition to information given by the local doctors. Thus, the quality of this information is also of importance. Regarding the validity of the results, it is important that the clinical methods are correctly performed, and that correct methods are chosen for the analyses of the results The patient group The WAD-2 group seems to be a rather homogeneous group related to the inclusion criteria from the Quebec report (Spitzer et al. 1995). At the first and second medical assessment they fulfilled the criteria by neck complaint and musculoskeletal signs. Musculoskeletal signs included decreased range of motion and point tenderness. When the project started in 1999, no new WAD classification was performed. It is thus possible that the WAD- 2 group is more heterogeneous than what was the intention. In comparison with results from other studies, either with respect to severity of symptoms, or to prevalence of MRI-verified changes, it is important to bear this in mind. Seven medical offices participated in the collection of patients, employing all together an average of 24 medical doctors. Due to heavy workload and possible lack of priority, it is possible that the quality of data given at the additional form at the medical offices was suboptimal. An indication of this is that for more than half of the patients, the additional information regarding the car accident was given on the physiotherapy form and not on the extra form distributed at the medical offices. On the first medical assessment, the patients were asked to answer some questions regarding the car accident. One of the questions was if the patient had sustained only one neck injury. The purpose of this question was to locate persons suffering after only one injury, as it then would be easier to associate clinical findings with that specific accident. Therefore, this question was emphasized in the letters to the medical doctors, and by the first clinical assessment performed at the FMC. When starting up the project in 1999, we therefore hoped that we had eliminated those with more than one neck injury. Today, in 2009, we have not the same certainty regarding this issue. FMC has now developed a rehabilitation program for neck injured persons, and 52 participants in the present study did come back to participate in this rehabilitation program. Rather unexpectedly, several of these patients gave new information indicating that they in fact had sustained more than one neck injury. These new traumas could either be another car accident, or neck injuries of other types. When asked why this had not been reported earlier, different answers were given. Some of the patients had not been aware that it was that important that they had sustained only one injury; for others, it was the registered injury that muskel&skjelett nr. 1, februar

20 FORSKNING Whiplash after their opinion gave them the largest symptoms. Others had not been sure of what the criteria were for a neck injury, and some also had an unfinished case with the insurance company, and therefore it was important for them to register only one neck case The time of the injury In some cases we probably had the wrong date for the neck injury. Some of the patients did not see a medical doctor immediately after the injury. In some cases, the patients thought that the pain and functional disability should disappear; in others the pain and functional disability gradually increased over time. Thus, it later turned out that the date given by some of the patients as the date of the accident was the date they first realized the pain or decided to seek medical advice. The exact number is not known. These uncertainties may have influenced the results and conclusions of article two, where the aim was to find out if the MRI findings could be associated with accident related factors. With the possibility of more than one trauma, this correlation becomes doubtful. This new knowledge impairs our conclusions, and we therefore have to use the results with caution. For the three other articles, it is highly unlikely that this bias could interfere with the results and conclusions The control group The control material was randomly drawn among persons that were referred for physiotherapy for diagnoses outside the head and neck area. That means that the control persons probably were more affected by muscle and skeleton problems than completely healthy control persons would have been and consequently, that they scored higher on the disability index (Kaale et al. 2005a) than more healthy controls would have done. It is a possibility that our control group had a higher level of muscle and skeleton problems to the lower back and extremities compared to a general population group. Thus, the difference between WAD persons and control persons may have been even larger if we had drawn control persons from the general population. On the other hand, WAD person may have exaggerated their symptoms. In summary, we believe that the results from this study are based on a fairly representative sample of WAD-2 patients and control persons without a diagnosis of WAD. 5.2 Validity and reliability of clinical methods and patient-given information Neck Disability Index Score (NDI) The NDI questionnaire is a condition specific instrument, thought to be sensitive to changes in symptoms, and easy to use in clinical practice (Ackelman et al. 2002). In Sweden, a Swedish version of the NDI has been used, demonstrating good validity, sensitivity and testretest reliability, but not optimal specificity (Ackelman et al. 2002). It is important to map all aspects of WAD. Consequently, some authors have suggested incorporating questions regarding social and emotional matters (Ackelman et al. 2002, Hoving et al. 2003, Cleland et al. 2006, Vo et al. 2006). On the other hand, others have claimed that there has been a trend to overpsychologise the WAD patients, and thereby overlook the somatic origin for their symptoms and functional disabilities (Cote 2001, Bergholm 2003, Johansson 2006, Maak 2006). We wanted to emphasise on the possible somatic aspects, and therefore did not include such questions in our questionnaire. Co-morbidity may be a problem when a patient tries to estimate the degree of particular disability. For instance, headache is quite common in the general population and is not necessarily a part of the neck syndrome. Ackelman et al. showed in their study that for the concurrent validity, a high degree of pain for the chronic neck pain patients in most cases did not correspond with high levels of NDI. Misunderstanding of this issue could result in an overestimation of the scores of this particular item, and also influence the answers for the other questions. A possible modification of the NDI instrument could be that the patient was asked to emphasise only disability due to neck pain. In the present study, however, this would make comparison with responses in the control group difficult. The NDI questionnaire does not reflect the full spectrum of disabilities judged to be important by the WAD patient. Issues concerning emotional and social functioning are not addressed properly in this questionnaire (Hoving et al. 2003). For the WAD patient group it is important to assess issues concerning emotional and social function to daily life. The results from Hoving et al. indicate that the social consequences of the pain and functional disability are important aspects of the subject s situation that is not covered by the NDI. Correction for missing values has been a challenge using the NDI. For instance, the item concerning driving may be an unanswered question (Vos et al. 2006). In our study, no correction for missing values was necessary for any item. A study by Cleland reported poor construct validity using the NDI questionnaire. This questionnaire was less responsive to changes in each item compared to other questionnaires. They propose using the Patient Specific Functional Scale (PSFS). The PSFS exhibited significantly greater changes in score, while changes in the NDI did not differ between improved and stable patients (Cleland et al. 2006). 20 muskel&skjelett nr. 1, februar 2010

21 Whiplash FORSKNING Head position and impact direction Through the Firda rehabilitation program, we followed-up the question regarding neck position at the time of accident (Kaale et al. 2005b). That work gave us some new information. Our goal in the present study was to registered either front or rear end collision, and connect the individual cases with either neutral or rotated neck position during the time of accident. With increasing knowledge over the years regarding the biomechanical conditions around a car accident, we now realize that the information given to the patients at the first registration was insufficient. Sometimes it can be difficult to register the first strike in a car collision. A car collision may also often contain more than one hit, from different directions and with different hit points. Thus, there might have been problems with the patients registering and estimating the force on the neck and head in a fast upcoming series of blows during the accident. Impulses from high noises and scaring sights may also have influenced the total impression of the car accident, and thereby influenced the patients perception of the direction of the impact. With regards to neck position, we only asked whether the neck was rotated at the moment of the accident or not. However, there may be a difference between going into a rotated neck position and going out of it, as these are two completely different movements. Going into rotation stretches some types of soft tissues, whereas going from a rotated position back to a more neutral position may relax the same tissue tension. This important distinction was not clea to the patients or to us at the time of registration. Thus, there may be some uncertainties regarding the information given by the patients about hit-directions and neck position Active range of motion (AROM) The cervical range of motion (CROM) device employed in this study is easy to use, and it seems to be a potentially useful tool for the clinician. Studies have shown acceptable intra tester and inter tester reliability (Capuano-Pucci et al. 1991, Youdas et al.1991, Youdas et al. 1992). Capuano-Pucci investigated a healthy group, and Youdas et al. did their works on both a healthy and a patient group. In my previous MSc graduation project (Kaale 1996), reliability of AROM was assessed on a control group (n=61) and four whiplash groups (n= 20 x 4), using the same device as in the present research project. The test/re-test results did not fall within the predefined acceptable limits of deviation in each direction, set to +/- 4o. Intra tester reliability was shown to be more reliable than inter tester reliability. Comparison of the results between control and patient groups showed a higher degree of conformity for the patient groups. There were no demonstrable differences between large and small movements. In clinical work, it is essential that clinicians are able to obtain the same measurement when a subject is retested. Likewise, testers must be confident that the inter tester reliability is acceptable. Tousignant et al. have evaluated the validity of the CROM device (Tousignant et al. 2000, 2002, 2006). The CROM device was found to be valid for measurements of active neck motion. Based on these studies, the CROM may be a useful tool for assessing AROM in the neck for both a normal population and for different patient groups. Experience from the present study (Kaale et al. 2007) shows that patients with neck problems, compared to persons with normal neck function, is often more difficult to assess, since neck symptoms can influence the test results. The individual level of neck function and level of symptoms may also vary from day to day. My experience with the CROM device used on a whiplash group includes several challenges, as indicated below. The subjects were given verbal instruction concerning the purpose of the testing. We tried to give the same information each time. We tried to control our voice, giving the information with the same speed and the same sensitivity and level of influence for each person. We experienced that it was difficult to control or adjust the person s own experience of our message. How far to go into a direction of motion, their own ability to control their own movement, when to stop, different level of acceptance of pain, how to cope with their own anxiety of possible pain, or consequences after neck motion were all challenges we had to cope with. We experienced that these challenges were not stable, and that they thus may have influenced the reliability and validity of our tests. We performed the test with a warm-up period consisting of three repetitions of each of 6 movements; extension, flexion, side bending (left and right) and rotation (left and right). Two measurements were taken for each of the six cervical motions. The second measurement was recorded and used in the analyses. Our patients had individual symptoms and functional deficits, as revealed in one or several of the testing directions. We experienced that the order of test direction could influence the result. If the main problem was extension, and that was the first testing direction, pain and functional provocation by that test movement could influence the results of other test directions. Sometimes a patient s level of pain and functional disability differed throughout the day. The changes could be a result of different activities of daily life, or a consequence of fluctuation of a soft tissue healing process. Such changes may also have influenced the reliability and validity of the AROM tests. Changes in AROM at one time, or over time, do not necessary reflect real changes in AROM. Changes to the better or worse may be a result of diffe- muskel&skjelett nr. 1, februar

22 FORSKNING Whiplash rent impacts. To secure a proper use of the CROM device, it is vital to try to control for these artefacts. We summarise this work by emphasising the uncertainty that the CROM device not necessarily reflect real changes in the AROM due to a neck injury. Changes in AROM may also be the result of patient related or method related fluctuations Clinical assessment based on manual therapy techniques When testing passive intervertebral motion by the use of clinical techniques, it is a challenge to prove the level of intra and inter tester reliability. Van Trijffel et al. have conducted a systematic review to determine inter examiner reliability of passive assessment of segmental intervertebral motion in the cervical spine (Van Trijffel et al. 2005). Nineteen studies were included in this review. Two studies satisfied criteria for external and internal validity, of which one found fair to moderate reliability. Assessment of motion segments C1-2 and C2-3 almost consistently reached at least fair reliability. Overall, inter examiner reliability was poor to fair. However, most studies were found to be of poor methodological quality. Fernández-de-las-Peñas C et al. conducted a study to determine if the lateral gliding test for the cervical spine was a valid clinical test compared with radiological assessment as a tool for the diagnosis of intervertebral joint dysfunction in the lower cervical spine in patients with mechanical neck pain. They concluded that the lateral gliding test for the cervical spine was as good as a radiological assessment for the diagnosis of intervertebral dysfunction in the lower spine (Fernández-de-las-Peñas C et al. 2005). Piva at al. conducted a study on inter tester reliability of passive intervertebral movement (PIM). Measurements of PIM tests resulted in moderate reliability of assessing atlanto-occipital mobility. They concluded that results of PIM tests were affected by neck pain reproduced by the tests. (Piva et al. 2006). These studies indicate that PIM tests of the cervical spine have poor to moderate inter tester reliability. Poor reliability and high levels of measurement errors reduce the usefulness of a test, and limits the extent to which tests results can be generalized. The tests in our study have not been through reliability tests, so we have no values indicating the level of reliability. The goal of our study was to see if changes in PIM could be verified by another diagnostic tool, the MRI. Changes in PIM may be a direct consequence after a soft tissue lesion. These possible soft tissue lesions may then be visualized by MRI. The level of agreement between clinical tests and radiological assessment may however tell us something about both the validity of the clinical tests, and what clinical consequences a positive MRI results may give in clinical testing for a specific tested motion. In summary, results from research performed by other authors on the reliability of PIM tests, indicate that these test so far do not meet the standards and levels of secure information. The level of intra and inter tester reliability is too low. We are not sure if the results reflect real clinical changes or if they are consequences of a methodological weakness. Our results indicate a connection between the MRI findings and the manual PIM tests. To secure a more reliable use of these clinical tests, a proper protocol has to be made on a scientific basic. With a proper protocol, this clinical approach may strengthen the assessment, and further choose those who need a radiological assessment. The recommendation from Jansen et al. was that only those who were classified as WAD 3 and 4 with neurological findings were justified for an MRI assessment (Jansen et al. 2008). The use of MRI verifying soft tissue lesion in ligaments, membranes and capsules in the upper cervical spine is still doubtful because of weakness with different types of MRI equipment and protocols, inadequate knowledge about clinical findings after a neck trauma, and normal variation of soft tissue structures Stressful life events and personality as parameters in predicting the duration and severity of symptoms after a whiplash trauma The present study did not have as an aim to investigate these aspects of the whiplash syndrome. Nevertheless, they may be of importance and will therefore be dealt with briefly below. Laxity in the ligaments in the upper cervical spine after a neck injury, with possible change in biomechanical function, may be an origin of pain. Even so, we cannot exclude psychosomatic causes of pain and functional deficit. Psychosocial factors may influence the posttraumatic course after a whiplash trauma, either by a premorbid personality that makes the patient more vulnerable to develop chronic pain, or because the chronic pain over time induces a change of personality in a direction that negatively influences the rehabilitation. Low expectation of personal success, low self image in family- and work relations combined with long-lasting distress, may predispose for a poor outcome after a whiplash trauma. A family history showing problems to deal with personal challenges and expectations of disability and possible neck symptoms existing prior to the trauma may be risk factors for development of chronic symptoms after a whiplash trauma, in some cases possibly more important than the organic changes caused by the accident itself (Van der Donk et al. 1991, Schrader et al. 1996, Karlsborg et al. 1997, Richter et al. 2004). 22 muskel&skjelett nr. 1, februar 2010

23 Whiplash FORSKNING MRI method Advanced MRI technology has since the late nineteen-nineties made it possible to detect ligament and capsular injuries in the cranio-cervical junction. A new MRI protocol for classifications of MRI signal intensity in cranio-cervical ligaments and membranes was developed by one of the collaborators in the present study (JK). To ensure that the criteria were mutually understood, a pilot study including ten cases was performed, and results based on the interpretations of different radiologists were compared and discussed, before this study was started (Krakenes et al. 2002). A detailed description of the classification system, as well as results from inters and intra observer variation studies are presented elsewhere (Krakenes et al. 2001, 2002, 2003 a, b) and in the thesis they were a part of (Krakenes J. MRI analysis of craniovertebral ligaments and membranes in the late stage of whiplash injury, Doctorial thesis, University of Bergen 2004). In the studies from Krakenes et al., the consistency in the grading of signals changes in craniovertebral ligaments and membranes varied considerably, both between observers and for the different structures evaluated. Inter observer agreement for the right alar ligament was moderate (0.41), and for the left alar ligament fair (0,31). The respective values with weighted kappa were 0.51 and 0.50, respectively. Main reasons for disagreement were intermediate signal in parts of or in the entire ligament width, reduced image quality, or erroneous use of criteria (Krakenes et al. 2001). In another recent Norwegian study that applied a classification similar to that in the present study, inter and intra observer agreements were rather similar to those observed by Krakenes et al. (Myran et al.2008). Inter-observer agreement improved considerably in both of these studies, however, when dichotomising into normal (grade 0-1) and abnormal (grade 2-3) categories. It is important to identify findings susceptible to different interpretations and to disclose sources of disagreement. Inconsistency in radiological diagnosis will mislead clinicians and reduce the usefulness of radiological examinations. A better understanding of the normal anatomy and injury patterns, combined with more experience in using the criteria, will probably reduce such inconsistencies. The consensus in Euro Spine 2008 ask for more reliable MRI studies of the ligaments in the upper part of the cervical spine in whiplash-injured patients in the acute phase (Jansen et al. 2008). MRI as an assessment tool for ligament injuries is not a new science. An example is the use of MRI detecting lesions to the cruciate ligaments. Fritz has focused on the MR imaging of meniscal and cruciate ligament injuries. The cruciate ligaments are about 38 mm long, and a width of 11 mm (Gray s Anatomy). He concluded in 2003 that MRI imaging provides clinically useful information in detecting and characterizing sports-related pathology of the menisci and cruciate ligaments in a non-invasive fashion. Acute and chronic tears of the anterior and posterior cruciate ligaments can be accurately identified and evaluated with MRI imaging (Fritz, RC 2003). The size of the cruciate ligaments is almost three times that of the alar ligaments. However, there are also studies that show how MRI can be used in really small structures. Carrino et al. has focused on magnetic resonance imaging-guided percutaneous biopsies of musculoskeletal lesions for which other imaging modalities might be inadequate. One of the main reasons for doing this work was the need for site-specific targeting within a lesion. The results showed that the performance of percutaneous biopsies can be very good for bone lesions, moderate for extra-articular soft-tissue lesions, and fair for intra-articular soft-tissue lesions. (Carrino et al. 2007). So far, the use of MRI in the study of specific ligaments and membranes in the upper cervical spine has not yet been established as an assessment procedure after neck traumas. The Euro Spine indicates a lack of knowledge regarding MRI changes in the upper cervical spin ligaments and membranes in the normal population. They also request a better consensus using the MRI equipment and MRI procedures (Jansen et al. 2008). In the present study we considered results from the MRI evaluation as being a correct classification of potential physical injury. The use of MRI as a gold standard is a challenge, since there so far are not established standards of MRI sequences or interprets routines (Jansen et al. 2008). As part of the reliability studies (Krakenes et al. 2000, 2001, 2003 a and b), the MRI evaluation was performed twice. When relating the MRI findings to clinical symptoms (Kaale et al. 2005a, 2007, 2008) and accidentrelated factors (Kaale et al. 2005b), we only considered results from the initial MRI examination, to ensure that the evaluations were blinded for study group. The prevalence reported by Krakenes et al. are based on the second evaluation, and differ thus slightly from those presented in the present study. 5.3 General discussion of results Association between MRfindings and clinical symptoms We found that WAD patients reported significantly more pain and functional disability than the control persons, both for total score and for each of the ten single items (Kaale et al. 2005a). The disability score increased with increasing number of abnormal (grade 2-3) structures among the WAD patients. We also observed that WAD patients had on average a shorter range of active motion for all movements compared with the control group (Kaale et al. 2007). The difference was statistically significant muskel&skjelett nr. 1, februar

24 FORSKNING Whiplash for all measures considered, except side bending to the left. Among the WAD patients, increasing severity of lesions to the alar ligaments was associated with a decrease in maximal flexion and rotation. An abnormal posterior atlanto-occipital membrane was associated with shorter range of rotation, with a significant trend test both in analyses with and without adjustment for lesions to other structures. Regarding passive test of joint motion, we found that the MRI-verified abnormalities correlated with a clinical detectable passive hyper-mobility (Kaale et al. 2008). The observed difference in severity of symptoms between WAD patients and control persons, together with the dose-response relationship in the analyses of associations of severity of symptoms and severity of MRI findings, indicate that subjective symptoms and complaints among WAD patients can be linked with physical injury signs to specific soft tissue structures in the upper cervical spine, in particular the alar ligaments. We cannot, however, draw conclusion with respect to whether the MRI verified lesions is caused by the whiplash episode or to any other unfavourable event. Results from studies like ours appear to have stimulated a debate regarding a possible organic origin of whiplash as demonstrated by MRI. Kwan et al. found the level of evidence weak: the patients were studied many years after their trauma; too little information was given about the type of trauma, any cervical manipulation that they had undergone, nor any history of other injuries. They also demand information about the prevalence of these appearances in ontraumatic neck pain (Kwan et al. 2004). So far, however, few studies have focused on the clinical aspects regarding the MRI findings on the cranio-cervical ligaments. Isolated MRI changes without clinical correlations are of little use. Clinical test of passive mobility of soft tissue structures in the upper cervical spine corresponded with signs of physical injuries, as judged by magnetic resonance imaging (Kaale et al. 2008). Considering all fourresponse categories, the kappa coefficient indicated moderate agreement (range ) between the clinical and the MRI classification. When there was disagreement, the classifications obtained by the clinical test were significantly lower than the MRI grading, but mainly within one grade difference. When combining grade 0-1 (normal) and 2-3 (abnormal), the agreement improved considerably (range ). The use of MRI for verifying lesions in the cranio-cervical ligaments is still in an early phase regarding approach to clinical findings and symptoms. A closer approach between radiological methods and clinical findings seems urgent for a more thorough understanding of this long lasting whiplash syndrome. There is still a considerable uncertainty regarding these MRI results and the clinical consequences of these MRI changes. Findings from Krakenes et al., showing reparative changes, with lack of fibre structure with connective tissue or fat replacement in the cranio vertebral ligaments indicate soft tissue lesion after a neck trauma MRI-verified lesions, WAD vs. control For all neck structures in the present study, that is the alar and the transverse ligaments, and the posterior atlanto-occipital and tectorial membranes, the whiplash patients had more high-grade changes (grades 2 or 3) than the control persons (Kaale et al. 2005b). The prevalence of high-grade changes was highest for the alar ligaments (66.3% graded 2 or 3). Signal changes in other structures often appeared in conjunction with lesions to the alar ligament. Soft tissue structures in the upper cervical spine visualized by MRI have earlier been described by several authors (Pfirrmann et al. 2000, Wilmink et al., 2001, Roy et al. 2004). These studies were performed on either healthy persons (Pfirrmann et al. 2000, Roy 2004), or on very small patient groups (Pfirrmann et al. 2000, Wilmink et al 2000, Roy et al. 2004). These works were not able to find any correlation between alar injuries and WAD traumas. In a recent Norwegian study, Myran and co-workers (Myran et al. 2008) described highsignal intensity changes in the alar ligaments among whiplash patients, patients with chronic neck pain, and in controls; no overall significant difference between the three groups was found. The authors concluded that the diagnostic value and the clinical relevance of magnetic resonance detectable areas of high intensity in the alar ligaments are questionable. However, no direct comparison of WAD patients and control persons was performed in this study. The proportion of abnormal (grade 2-3) alar ligaments in the chronic pain group was rather similar to those in the control group, whereas WAD patients more often had abnormal alar ligaments (Albrektsen et al., 2009, Myran et al, 2009; in press). Thus, results from the study by Myran et al. give some support to our findings, although the difference between WAD patients and control person was less pronounced than in our study. We considered the results from the MRI evaluation as being a correct classification of a potential physical injury. So far, however, there have not been established standards of MRI sequences or interpretation routines (Jansen et al. 2008). The consensus in Euro Spine ask for more reliable MRI studies of the ligaments in the upper part of the cervical spine in whiplash-injured patients in the acute phase (Jansen et al. 2008) Additional evidence for ligament and membrane injury Additional studies have focused on potential injuries in specific neck structures. Johansson described pronounced anatomical changes in three 24 muskel&skjelett nr. 1, februar 2010

25 Whiplash FORSKNING patients that underwent surgical fixation of the cranio-cervical junction after a neck injury, as well as widespread injuries with scar tissue in the C0/1 and C1/2 joint capsules, open joint cavities at the C1/2 level due to these capsule injuries, injuries to the dens related capsules, and granulation changes in the alar ligaments (Johansson 2006). Other authors have also supported this ligament injury hypothesis. Panjabi et al. advocated that cervical ligaments might be at risk for injury in a whiplash trauma due to excessive strain during the impact (Panjabi et al. 2004). Tominaga et al. support these findings with their results indicating a decrease in neck ligament strength due to whiplash trauma (Tominaga et al. 2006); other authors have suggested that soft tissue injuries in facet joints and capsular ligaments may be a consequence after a whiplash trauma (Siegmund et al. 2001, Pearson et al. 2004). Ivancic et al. have suggested that capsular ligament injuries, in the form of increased laxity, may be one component perpetuating chronic pain and clinical instability in whiplash patients. They demonstrated that the average length of the whiplashexposed capsular ligaments was significantly greater than that of the control ligaments (Ivancic et al. 2007) Associations between MRI findings and accident related factors We found that whiplash patients who had been sitting with their head/neck turned to one side at the moment of collision more often had high-grade signal changes of the alar and transverse ligaments than those who had not turned their heads (Kaale et al. 2005b). Severe MRI signal changes in the transverse ligament and the posterior atlanto-occipital membrane were more common in front than in rear end collisions. These findings support our theory that head position and impact direction at time of accident may influence location and degree of lesion of soft tissue structures in the neck. The association with the accident-related factors supports the hypothesis that the MRI verified signal changes in ligaments and membranes in the upper cervical spin are caused by the whiplash trauma. Several clinical and in vitro studies have indicated that direction and strength of external forces acting at time of accident is of importance for severity of injury. In 1983 Norris et al. postulated that injury of the neck might be the result when a motor vehicle runs into another from behind. They developed a classification system based on presenting symptoms and physical signs after a neck trauma. This work was a forerunner for the later WAD classification system (Spitzer et al. 1995). At that time only impacts from behind were included. Norris et al. did not consider head and neck position during impact. Later, frontal impacts and side impacts have also been included (Kullgren et al. 2000, Panjabi et al. 2004), and head position during impact has also been considered a risk factor after a whiplash trauma (Kumar et al. 2005, Maak et al. 2006, Panjabi et al. 2006). Panjabi et al. has performed several in vitro studies looking for soft tissue lesions after neck trauma. Investigating human cervical spine specimens, they have found that head-turned rear end impact caused significantly greater injury at C0-1 and C5-6, as compared to headforward rear and frontal impacts (Panjabi et al. 2006). Panjabi performed in 2004 a project, where they put up a whole cervical spine with muscle force replication model and a bench-top sledge to simulate frontal impacts. Their results concluded that the supraspinatus, interspinosus ligaments and the flavum ligament were at risk for injury due to excessive strains during frontal impacts (Panjabi et al. 2004). In an in vitro study, Maak et al. focused on lesions to the alar, transverse and apical ligaments after a whiplash trauma. They concluded that these ligaments were not at risk due to head-turned rear-end impacts under 8 G (Maak et al. 2006). A new research from 2008 by Siegmund et al. conclude in an in vitro study that head-turned posture increases the strain on facet joint capsular ligaments compared to a neutral head posture (Siegmund et al. 2008). These findings support the hypothesis that organic lesions may be a consequence after a whiplash trauma. 6.0 Summary and conclusion The results of this study give reasonable support to the existence of an organic model that in part can explain the problems of the long lasting whiplash syndrome. Results from studies published during the recent years have given additional support to such a model, but contrasting results have also been reported. Nevertheless, psychosocial factors may still be of importance for the development of the long-lasting whiplash syndrome in combination with organic causes, and thus of relevance in predicting the outcome with duration and severity of the complaints. Additional studies is still needed to gain better understanding of underlying biological mechanisms, possibly leading to improvements in diagnostic and therapeutic procedures. muskel&skjelett nr. 1, februar

26 FAG Aktuelt Ny rapport om muskel- og skjelettsykdommer Muskel- og skjelettsykdommer er den vanligste årsaken til sykefravær og kronisk sykdom i Norge. Konsekvensene av muskel- og skjelettsykdommer kan imidlertid reduseres med tidlig diagnostisering og tiltak, ifølge ny rapport. Det er The Work Foundation som står bak «Fit for work? Musculoskeletal Disorders and the Norwegian Labour Market.» Bare vondt i ryggen og rheumatoid artritt (RA) koster det norske samfunnet om lag 21 milliarder kroner i året. Cirka 23 prosent av alle norske arbeidstakere rapporterer om arbeidsrelaterte ryggsmerter. Ryggvondt er årsak til 13 prosent av alle sykmeldinger som varer mer enn åtte uker. Rundt 31 prosent av arbeidstakerne rapporterer om arbeidsrelaterte muskelsmerter i nakke, skulder, og/eller armer/ben Cirka mennesker har RA og 40 prosent av disse er uførepensjonert. Rapporten beregner at RA koster det norske samfunnet 6,2 milliarder kroner. Tidlig diagnostisering og behandling kan ifølge The Work Foundation redusere de sosiale og økonomiske virkningene av muskel- og skjelettsykdommer. Det bør derfor fokuseres mer på dette for å redusere andelen med muskel- og skjelettsykdommer som søker uføretrygd. Fant ikke sammenheng mellom korte iliotibialbånd og LBP Hypotesen om at forkortet iliotibialbånd (ITB) og korsryggsmerter støttes ikke av en studie som AM Arab og MR Nourbakhsh har gjennomført. I teorien har man tenkt seg at korte ITB er en kompensasjonsmekanisme som følger av muskelsvakhet i hoftens abduktorer. Tøyning av ITB anbefales derfor ofte når det gjelder behandling av ryggvondt (LBP). 300 personer mellom 20 og 60 år med og uten LBP deltok i den kryss-seksjonelle studien. Deltakerne ble fordelt på tre grupper: (1) LBP med korte ITB (2) LBP uten korte ITB og (3) ikke LBP. Hofte abduktor muskelstyrke ble målt hos alle. Analysene viste at det ikke var noen signifikant forskjell når det gjaldt styrke i abduktorene hos de som hadde LBP (gruppe 1 og 2). Forskerne konkluderer derfor at hypotesen om en sammenheng mellom forkortet ITB og LBP ikke støttes av denne undersøkelsen. Amir M Arab and Mohammad R Nourbakhsh: The relationship between hip abductor muscle strength and iliotibial band tightness in individuals with low back pain. Chiropractic & Osteopathy 2010, 18:1 Innspill om Samhandlingsreformen Norsk Manuellterapeutforening ber om at allerede eksisterende modeller tas i bruk i Samhandlingsreformen. Potensialet i pasientrettighetsreformen av er ikke utnyttet, heter det i foreningens innspill til Helse- og omsorgskomiteen. NMF mener grunnen til at pasientrettighetsreformen der manuellterapeutene fikk ny yrkesrolle ikke er utnyttet fullt ut, er dårlig informasjon og mangelfull identifikasjon av manuellterapeuter. Full utnyttelse av reformen vil kunne bidra til tidligere intervensjon på muskel- og skjelettområdet, lavere sykepengeutbetalinger og færre henvisninger til spesialisthelsetjenesten og røntgen/mr, heter det bl.a. i innspillet. Også Norsk Fysioterapeutforbund har spilt inn synspunkter på Samhandlingsreformen. I sitt notat til komiteen nevner imidlertid ikke forbundet manuellterapeuter eller manuellterapeutenes rolle. Komiteen legger etter planen fram innstilling i saken 20. april. 26 muskel&skjelett nr.1, februar 2010

27 Aktuelt FAG Trange sko kan gi feilstilling av stortå Det er en klar sammenheng mellom bruk av trange sko og feilstilling av stortåen hos førskolebarn. Hallux valgus (hallux=stortå, valgus=utoverforskyvning) betyr at stortåen er vridd mot lilletåen. Samtidig er stortåens grunnledd delvis ute av ledd. Dette kan utvikle seg til en smertefull tilstand. Årsaken er ikke fullt klarlagt, men en hypotese har vært at trangt skotøy kan bidra. Østerrikske forskere undersøkte føtter og skotøy til 858 førskolebarn. Resultatene viste at bare 23,9 av stortærne på de undersøkte føttene pekte rett fram. 14,2 prosent hadde stortær som var vridd mer enn 10 grader. 88,8 prosent av barna hadde innesko som var for trange, mens 69,4 prosent hadde for små utesko. Ideell lengde på sko er 12 millimeter lengre enn fotens lengde. En analyse viste at det var sterk sammenheng mellom trange sko og hallux valgus. Det faktum at majoriteten av barna hadde for trange sko understreker betydningen av at man sørger for at barn har fottøy som passer. Oversikt over hvordan de undersøkte føttene fordelte seg: Smerte smitter Smerte i en menneskelig muskel kan spre seg til friske muskler som slett ikke er kommet til skade, skriver forskning.no Ny dansk forskning viser at muskelsmerter kan spre seg til områder som ikke har vært rammet av skader. Og hva verre er: Den nye smerten i armen kan bli værende selv om den opprinnelige tennisalbuen for lengst er blitt frisk igjen. I gamle dager var smerte noe man kunne merke ett sted. Nå har vi funnet at smerten godt kan spre seg fra for eksempel albuen eller kneet, slik at man føler man har smerter i store deler av hele kroppen, forteller Thomas Graven-Nielsen, professor på Senter for sansemotorisk interaksjon (SMI) på Aalborg universitet. Og det skal ikke så mye til; bare det å bruke en verkende muskel i lengre tid er sannsynligvis nok. Professoren vet til ikke hvorfor smerte smitter eller blir hengende igjen i andre muskler når den opprinnelige skaden er reparert. Smerte oppstår typisk for å beskytte kroppen. Men det er jo ikke noe poeng i at man, bare fordi man har vondt i kneet, også får vondt i hele kroppen og fortsetter med å ha det vondt også når man ikke lengre har smerter i kneet. Så umiddelbart er det vanskelig å få øye på den store relevansen, og det er ikke sikkert at det har noe formål, sier han til forskning.no. Referanse Thomas Graven-Nielsen: Spatial and temporal aspects of muscle hyperalgesia induced by nerve growth factor in humans (Experimental Brain Research) muskel&skjelett nr. 1, februar

28 AKTUELT gir alle terapeutgrupper en effektiv hverdag Pasientregister Journal Dagbok Epikriser Regnskap Økonomi Resepsjonsløsning Online Booking Administrasjon av helseforsikring SMS, e-post Integrasjon med Exor og Physiotools Legiokontroll Integrasjon av WinMed Administrasjon av treningssal Avtalegiro Sykemeldinger Henvisninger Kobling mot Norsk Helsenett Enkelt NAV oppgjør Mer enn 4900 brukere i Norge Kontakt oss for dagens løsninger Programvare forlaget AS PROGRAMVAREFORLAGET AS Tlf: / 28 muskel&skjelett nr. 1, februar 2010